Episode eighteen of Inside Covid-19 is a very special edition with a couple of ICU inmates – one local, another from New York – and the icon’s long time PA Zelda le Grange sharing What Would Madiba Advise. We’ll also hear how Vodacom is investing hundreds of millions right now to ensure its network can handle a 50% surge in lockdown data traffic. Plus US President Donald Trump’s explanation for suspending financial support to the World Health Organisation. – Alec Hogg
First in the Covid-19 headlines today:
- The South African death toll rose by seven Wednesday to 34. Six of them were from KwaZulu-Natal and five had underlying medical issues, including a 91 year old with diabetes. The two with no known medical problems were both 79 years old. A statement from the Department of Health says total confirmed infections rose to 2,506, an increase of 4% from Tuesday. Globally, confirmed infections broke through the 2m mark with deaths now approaching 130,000. The mortality rate in the UK. European countries have the highest proportionate deaths with Spain now at 38.6 per 100 000 of population, followed by Belgium at 36; Italy at 35; France at 23; the UK at 18 and the Netherlands at 17. The US’s mortality rate per 100,000 is 7.8, while South Africa is a long way behind at 0.05.
- As mention in the intro, the big news today is US President Donald Trump’s suspension of his country’s WHO funding. It is an about turn from February 24 when Trump praised the WHO in a tweet, saying it was “working hard and very smart… The coronavirus is very much under control in the USA.” The US is the world’s worst hit country with 24,000 deaths and over 600,000 confirmed cases with Trump now claiming the WHO is responsible by being too deferential to China. Again, in January Trump praised China’s response to the coronavirus. More on that story later in this episode.
- Still in the US, the state of South Dakota has deviated from the national theme with its Republican Governor Kristi Noem refusing to impose any kind of lockdown. She described such edicts as a “herd mentality” saying it was up to individuals, not government, to decide “whether to exercise their right to work, to worship and to play. Or even to stay at home.” South Dakota’s experience is sure to be closely watched – the state currently has six deaths from 988 confirmed infections.
It’s always good to be talking to people from the front line, as it were, of the fight against Covid-19 and Dr Lliam Brannigan is one of those. Lliam, in the research (before our conversation) – I see that you are what is called an intensivist. In other words, somebody who works in helping patients in intensive care. Have I got that right?
Yes, that is correct. I’m an intensive care specialist – otherwise known as an intensivist.
Before we go into the South African issue and the other discussion we’re having – we know that the UK Prime Minister, Boris Johnson, was in intensive care in the UK for three days. He was on oxygen, but not on a respirator – and people outside of the medical fraternity are wondering why that is relevant. Can you unpack what might have happened there?
Yes, so one of the reasons for being admitted to the intensive care unit – particularly for coronavirus, but for other viral pneumonias and other types of pneumonia – is because of hypoxemia or low levels of oxygen in the blood. This can obviously be the precursor to multi-organ failure, so it’s one of the most common reasons why we admit someone to an intensive care unit. And certainly, one of the issues around the use of a ventilator or not is one of the big controversial issues, because the ventilator isn’t of itself something that causes lung injury in the context of viral pneumonia. So often, the patients are just admitted for oxygen therapy and other treatment and we actively avoid ventilating them. And then, if we do have to ventilate them – we employ something called lung protective strategies.
When you get to the point with Covid-19 that you need to go to hospital – that’s usually because you need specialist care. When that doesn’t work out – you land up in ICU. And if I understand you correctly, that’s where you need oxygen first and if that doesn’t work out – then a ventilator is almost a last resort.
Yes. And leaning on years and years of experience with viral pneumonias – as a sort of central tenet – we always try to avoid the invasive ventilation of these patients yet, we often have no choice but to do that. But it’s very correct to say that it’s quite far down the management line and certainly shouldn’t be a primary priority for clinicians to get patients onto ventilators. It’s not the treatment of this disease.
Lliam, how accurate are the reports that say once you’re on a ventilator – the chances are very high that you’re never going to come out of hospital alive (with Covid-19?)
It’s very important to contextualise those reports. Equally important, is the context of who the ventilator was given to. So, certainly patients who are older, who have a lot of comorbid disease, who have lots of other problems – those patients tend to do significantly worse in all circumstances if they require organ support such as ventilation. So, I think, the reports are quite accurate – that the mortality rate is high on the ventilator, but should be contextualised with respect to the age of the patients going onto the ventilator, their comorbid disease (which may contribute to the seriousness of their multi-organ failure scenario) – but certainly the reports out of the First World are, I think, accurate.
What drew you to this side of medicine? I see you were a heli-doctor – which, presumably, is someone who really has to go into situations where people are very critically ill or the health is critical – and then you’ve been in critical care and as you say, an intensivist. Why?
I think for me (and for most of my colleagues) – I did medicine to help really sick patients and the sickest patients tend to occur in the intensive care unit. But also – the work is fascinating, the science behind it is fascinating (it’s a constantly growing field), and dealing with patients and their families at that time is also extremely rewarding because it’s generally a very traumatic time for families and the patients. And so, on multiple levels it’s an extremely rewarding profession.
You spend a lot of time with critically ill patients – presumably – those who’ve had transplants, those whose immune systems are specifically lowered so that the organs won’t be rejected by the body.
Yes. So certainly, these are the patients (particularly at the hospital where I work) that we are most concerned for. The reality is that, whilst it makes scientific and physiological sense that those patients be at high risk etc., we just don’t know what the impact will be if and when the tsunami of the Covid-19 outbreak hits us. We’re trying our best to both prepare for that inevitability and also to try and make sure that we have the resources available to treat those patients – should they get ill with Covid-19 and require assistance. They are a big concern for us and, in my area, remain my number one priority and concern at the moment.
How do you advise them?
The most important thing for them to do is to stay away from public interaction – so, we really encourage them to isolate aggressively. Then, it is very important that we stay in constant contact with them with respect to symptom identification and management. If they then escalate in terms of their symptomatology – it is important that we get them into a hospital a lot earlier than we would, say, get a patient with a normal immune system. So, most immunocompetent patients we would suggest to be managed at home. With the immuno-incompetent patients – we would be a bit more wary about the rapidity with which they could become really critically ill.
There is a school of thought that says ‘Go The Swedish Way‘ – allow everybody just to mingle and get the herd immunity and if people die, people die – and you can almost have some sympathy, from an economic perspective, for that argument.
Yes, so Alec, again – it’s a very complex problem but one that we talk about every day. So, the first issue is around the baseline mortality that exists around the world, which seems to be very different. So, you can be in one country with a mortality rate of about 1% and then in another country with a mortality rate of 12 or 13% – that’s a tenfold increase in your risk of dying. So, that’s problematic. The second issue is that there is some credence to what you would call an intelligent lockdown – where you would then say, for example, keep the schools open and the low risk populations working and isolate high risk populations (such as the elderly and immunocompromised). This can be quite difficult to do from a resource point of view and we just don’t know if that would result in herd immunity. There’s some controversy with respect to Corona Verde as a group in terms of herd immunity as well. And then lastly, the issue around the economic impact and whether or not that may result in a significant economic downturn and the impact on mortality that that would have. So, it’s really a constant issue and concern and this, I think, is where the South African government (and I’m sure you saw Prof Graham’s report a couple of nights ago) is doing exactly what it should be doing – which is to try and respond preemptively, but in the most non-invasive ways so that the collateral impacts of this pandemic are limited and we don’t land up sitting with a lot of problems that we ourselves created.
A lot of your fellow scientists have said that science doesn’t work at the speed of newspapers and it goes a lot more slowly, but even in that context; how long do you think it might be before we have enough knowledge to know with certainty what to do about this – whether it’s opening the lockdown, getting a vaccine or knowing which drugs to use for those who are infected?
That’s quite a difficult question to answer because, in the context of the info-demic that we face nowadays as well (constantly being given huge amounts of information – some of it not very good – in terms of the disease), it’s quite difficult to know what to do in the face of this pandemic. A vaccine etc. is probably quite some time away – I would think no earlier than September, October this year (at the earliest). And the key really will be whether we can get that going as soon as possible to try and prevent the infection from occurring.
